RETIRED LCD Reference Article Billing and Coding Article

Billing and Coding: MolDX: NSD1 Gene Tests

A53585

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Draft Articles are works in progress and not necessarily a reflection of the current billing and coding practices. Revisions to codes are carefully and thoroughly reviewed and are not intended to change the original intent of the LCD.
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General Information

Source Article ID
N/A
Article ID
A53585
Original ICD-9 Article ID
Not Applicable
Article Title
Billing and Coding: MolDX: NSD1 Gene Tests
Article Type
Billing and Coding
Original Effective Date
10/01/2015
Revision Effective Date
11/07/2019
Revision Ending Date
04/30/2024
Retirement Date
04/30/2024

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Article Text

Effective for dates of service on and after June 26, 2013.

NSD1 gene testing may be performed during the diagnosis of Sotos Syndrome. Since testing is limited to reproductive risk assessment, the MolDX Team has determined NSD1 gene testing is a statutorily excluded service. MolDX will also deny tests that include one or more of NSD1 analysis reported with CPT® code 81479 as statutorily excluded tests.

To receive a NSD1 analysis service denial, please submit the following claim information:

  • Select appropriate CPT® code according to genetic material tests
    • Code 81405 for NSD1 duplication/deletion
    • Code 81406 for NSD1 gene sequencing
    • Code 81479 for combinations of NSD1 analysis
  • An Advance Beneficiary Notice (ABN) is not required for statutorily excluded services.
    • For a voluntary issued ABN, append with GX modifier
    • To indicate a valid ABN is on file for a known statutorily excluded service, append with a GY modifier
  • Enter DEX Z-Code™ identifier adjacent to the CPT® code in the comment/narrative field for the following Part B claim field/types:
    • Loop 2400 or SV101-7 for the 5010A1 837P
    • Box 19 for paper claim
  • Enter DEX Z-Code™ identifier adjacent to the CPT® code in the comment/narrative field for the following Part A claim field/types:
    • Line SV202-7 for 837I electronic claim
    • Block 80 for the UB04 claim form

 

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Coding Information

Bill Type Codes

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CPT/HCPCS Modifiers

Group 1

(2 Codes)
Group 1 Paragraph

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Group 1 Codes
Code Description
GX NOTICE OF LIABILITY ISSUED, VOLUNTARY UNDER PAYER POLICY
GY ITEM OR SERVICE STATUTORILY EXCLUDED, DOES NOT MEET THE DEFINITION OF ANY MEDICARE BENEFIT OR, FOR NON-MEDICARE INSURERS, IS NOT A CONTRACT BENEFIT
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ICD-10-CM Codes that Support Medical Necessity

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ICD-10-CM Codes that DO NOT Support Medical Necessity

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ICD-10-PCS Codes

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Bill Type Codes

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims.

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Revenue Codes

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the article should be assumed to apply equally to all Revenue Codes.

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Other Coding Information

Group 1

Group 1 Paragraph

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Group 1 Codes

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Coding Table Information

Excluded CPT/HCPCS Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
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Non-Excluded CPT/HCPCS Ended Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
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Revision History Information

Revision History Date Revision History Number Revision History Explanation
04/30/2024 R9

This article is being retired because it is not supported by a Local Coverage Determination (LCD) and does not comply with current 21st Century Cures requirements.

11/07/2019 R8

Under Article Text deleted the statement “Select the appropriate diagnosis for the patient”. Under CPT/HCPCS Codes Group 1: Codes deleted CPT® code 81406. Under CPT/HCPCS Codes Group 2: Paragraph added verbiage, “CPT® codes that are also referenced in other articles”. Under CPT/HCPCS Codes Group 2: Codes added CPT® code 81406. CPT® was inserted throughout the article where applicable.

10/31/2019 R7

This article is being revised in order to adhere to CMS requirements per chapter 13, section 13.5.1 of the Program Integrity Manual. Under Article Title changed the title from “MolDX: NSD1 Gene Tests Coding and Billing Guidelines” to “Billing and Coding MolDX: NSD1 Gene Tests”. Under Article Text removed the last paragraph. Under CPT/HCPCS Modifiers Group 1: Codes added modifiers GX and GY.

 

01/01/2019 R6

Deleted 81403 from the article. Added all CPT code: 81405, 81406, and 81479 to CPT/HCPCS Codes Group 1. These codes were previously in the article, but not in the CPT/HCPCS Codes Group 1 field. This change is due to the CPT/HCPCS 2019 Annual Update and is effective 1/1/19.

 

02/26/2018 R5 The Jurisdiction "J" Part A and Part B Contracts for Alabama (10111/10112), Georgia (10211/10212) and Tennessee (10311/10312) are now being serviced by Palmetto GBA. Effective 02/26/18, these 6 contract numbers are being added to this article. No coverage, coding or other substantive changes (beyond the addition of the 6 Part A and B contract numbers) have been completed in this revision.
07/06/2017 R4

Added Part A contractor numbers to article. Updated Part A and Part B billing instructions.

11/19/2015 R3 Changed "MolDX ID (MID) field" back to read SV101-7
11/19/2015 R2 Replaced SV101-7 with MID, Removed Palmetto GBA reference and replaced with MolDX.
10/01/2015 R1 Updated 2015 CPT codes and completed Annual Validation.
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Associated Documents

Medicare BPM Ch 15.50.2 SAD Determinations
Medicare BPM Ch 15.50.2
Related Local Coverage Documents
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Public Versions
Updated On Effective Dates Status
04/30/2024 11/07/2019 - 04/30/2024 Retired You are here
10/30/2019 11/07/2019 - N/A Superseded View
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

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